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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 4  |  Page : 154-159

Evaluation of peripheral arterial disease in type 2 diabetic patients using computed tomography angiography


1 Department of Diagnostic Radiology Sciences, College of Medical Applied Sciences, Hail University, Hail, Saudi Arabia
2 Department of Diagnostic Radiologic Technology, Faculty of Applied Medical Sciences, Taibah University, Al-Madinah, Saudi Arabia
3 Department of Radiological Science, Batterjee Medical College, Jeddah, Saudi Arabia
4 Department of Medical Imaging and Radiation Sciences, College of Applied Medical Sciences, University of Jeddah, Jeddah, Saudi Arabia

Date of Submission14-Jun-2020
Date of Decision28-Jul-2020
Date of Acceptance16-Aug-2020
Date of Web Publication11-Feb-2022

Correspondence Address:
Dr. Moawia Gameraddin
Department of Diagnostic Radiologic Technology, Faculty of Applied Medical Sciences, Taibah University, Al-Madinah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/smj.smj_68_20

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  Abstract 


Background: Peripheral artery disease (PAD) in patients with Type 2 diabetes mellitus (T2DM) has broad characteristics and various complications. Aim: The purpose of this study is to evaluate PAD in T2DM and their association with age, gender, and the duration of T2DM. Materials and Methods: This study is a prospective cross-sectional one conducted at the radiology department in Royal Care International Hospital, Khartoum, Sudan, over 3 years. A total of one hundred and ten patients, 69 males and 41 females, were examined using MDCT. A binary logistic regression test was applied to identify independent predictors of PAD. Results: PAD in T2DM is found to be 50.91% atherosclerosis, 43.64% plaques, 29.09% stenosis, and 14.55% thrombosis (mean age 65.84 ± 9.57 years; mean duration of T2DM 29.37 ± 6.7 years). The prevalence of PAD was common in patients over 60-year-old. Atherosclerosis is significantly higher in males than females (59.4% vs. 36.6%, 95% confidence interval = 1.092–5.600, P = 0.03%). Plaques and stenosis of lower-extremity arteries were higher in males than females 44.9% vs. 41.5% and 29.0% vs. 29.3%) respectively. The incidence of thrombosis was higher in femoral arteries than lower distal arteries, and the prevalence was higher in females than males (22% vs. 10.1%, odds ratio = 2.228), respectively. Conclusion: Atherosclerosis, plaques, stenosis, and thrombosis were the most common PAD findings in patients affected with T2DM. Age, gender, and duration of diabetes, relatively risk factors associated with PAD. Thrombosis is more prevalent in the femoral artery than lower distal arteries.

Keywords: Atherosclerosis, multidetector computer tomography, peripheral arterial disease


How to cite this article:
Salih M, Gameraddin M, Yousef M, Malik BA, Alshammari QT, Bilal D. Evaluation of peripheral arterial disease in type 2 diabetic patients using computed tomography angiography. Sahel Med J 2021;24:154-9

How to cite this URL:
Salih M, Gameraddin M, Yousef M, Malik BA, Alshammari QT, Bilal D. Evaluation of peripheral arterial disease in type 2 diabetic patients using computed tomography angiography. Sahel Med J [serial online] 2021 [cited 2022 May 24];24:154-9. Available from: https://www.smjonline.org/text.asp?2021/24/4/154/337492




  Introduction Top


Type 2 diabetes mellitus (T2DM) is a risk factor for developing peripheral artery disease (PAD) and enhances the process of acquiring inflammatory conditions with severe complications and consequences on mortality and morbidity.[1] PAD in patients with T2DM exhibits various clinical characteristics and outcomes and is considered as one of the leading vascular complications of T2DM.[2] PAD is a slowly developing the narrowing of peripheral vascular lumen caused by atherosclerosis, which in turn reducing the blood perfusion in the affected region. The incidence of PAD is correlated with the age of T2DM and increased survival of the probability of acquiring cardiovascular diseases and stroke, which allows PAD to become symptomatic.[3] Patients with PAD are clinically assessed with the help of a brachial ankle index (ABI) coupled with ultrasound, ultrasound Doppler and computed tomography angiography (CTA).[3],[4]

Lower-extremity CTA is an efficient, accurate, and robust imaging method that is being used increasingly to evaluate patients with PAD.

CTA has high resolution to assess the lower limb vasculature and provides an accurate diagnosis of PAD. It demonstrates an exact location of the blood vessel stenosis before revascularization.[5],[6],[7] The increasing availability of multi-detector CT (MDCT) has improved clinical practice.

Patients with PAD may get a multitude of problems, such as claudication, severe ischemic pain, foot ulcerations, revascularizations, repeated hospitalizations. These disorders may be subjected to amputations. This may lead to reduced life quality and psychological problems.

This study aims to evaluate the vascular abnormalities of lower-extremity arteries and their association with age, gender, and duration of T2DM.


  Materials and Methods Top


Patient population

This is a cross-sectional descriptive single-center study conducted at the radiology department of Royal Care International Hospital (RCIH), Khartoum, Sudan, from the period of January to December 2016. A total of 110 patients, 69 males and 41 females, were selected using a convenient sampling method. They were studied using MDCT with a detailed data flow sheet. The study was approved by the ethical committee of RCIH on December 2015. Informed consent was signed from every patient. All patients suspected with PAD were included in the study. The exclusion criteria were patients with hyperlipidemia, hypertension, fractures at the lower limbs, and previous or recent history of surgical operation at vessels of the pelvis or lower limbs. The patients came with clinical data of PAD complained of symptomatic PAD who underwent MDCT angiography. They were referred from vascular surgeon physicians. The images of a 64-MDCT angiography were interpreted by two expert radiologists separately.

The referring surgeons indicated that the ABI values on the request of these patients were 0.7. An ABI ratio under 0.90 was considered abnormal. An ABI ratio between 0.41 and 0.90 is assessed as a mildly to moderately reduced blood flow, and an ABI <0.40 is evaluated as severely elevated blood flow.[8],[9]

The imaging procedure using 64-MDCT technique

The patients were assessed using a CT machine of 64-multiple slices CT. A protocol parameter for lower extremity CTA studies (CT acquisition parameters were based on a standard protocol of PAD) includes 120 kVp, 175–300 mAs, collimation of 64 mm × 0.6 mm, the gantry rotation speed of 0.37 s, the pitch of 0.65. The slice thickness was 0.5–2.0 mm with a reconstruction interval of 0.5–1 mm. A 100–120 ml (according to patient weight and age) of iodinated IV contrast medium was injected at a rate of 4–5 ml/s, followed by a normal-saline flush. The study utilized volume rendering as a diagnostic procedure in the diagnose of vascular disorders.

Statistical analysis

Computer package SPSS (version 23.0; SPSS, Chicago, III, USA) was used for statistical analyses. Qualitative data were presented as frequency, mean and standard deviation. A Chi-square test was used to find the association of age and gender with the MDCT findings. A logistic regression test was performed to determine the predictors and association of PVD with their prevalence in peripheral arteries of the lower limb. Odds ratio (OR) was used to find association of the diagnosed PAD with their incidence in the vessels of the lower limb. OR >1 indicates significant association of presence of vascular disease in certain vessel, whereas OR <1 indicates less association. For example, the OR of thrombosis in the femoral artery (FA) was 2.228, which indicates that FA is more likely to get thrombosis two times than the other arteries. The other values of OR have to be interpreted in the same manner. “The significance threshold was set at 0.05.”


  Results Top


A total of 110 patients indicated to have signs and symptoms of vascular diseases were examined using multi-detector CT (MDCT). They were 69 males and 41 females (male: female ratio is 1: 0.6). The mean age was 65.84 ± 9.57 years, and the mean duration of Type 2 DM was 29.37 ± 6.7 years. [Figure 1] and [Figure 2] were MDCT images show multiple atherosclerosis in peripheral arteries. The duration of Type 2 DM in males was slightly longer than that of females (30 vs. 28 years), as shown in [Figure 3]. Most of the patients were in the age groups of 61–70 years 71–80 years, as shown in [Table 1]. The symptoms and signs were demonstrated in [Figure 4]. The pain was the main symptom among the participants (49%), while claudication was 20%, cellulitis was the minimal one (1.8%).
Figure 1: MDCT image of an 83-year-old, shows multiple atherosclerosis in abdominal aorta and lower limb arteries

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Figure 2: MDCT image of a 63-year-old male shows multiple sclerosis in peroneal artery

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Figure 3: Duration of Type 2 diabetes mellitus in males and females

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Figure 4: Symptoms and signs of PAD in patients with Type 2 diabetes mellitus

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Table 1: Demographic characteristics of patients with type 2 diabetes mellitus

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Atherosclerosis was significantly higher in males than females (59.4% vs. 36.6%, P = 0.030). The likelihood of various atherosclerotic lesions in lower limb arteries are shown in [Table 2]. The other vascular diseases have no significant difference between males and females (P < 0.05), as shown in [Table 3]. The prevalence of thrombosis was higher in females than males without significant difference (22.0% vs. 10.1%), respectively.
Table 2: Computed tomography diagnosis of lower extremity arterial diseases and their location in various blood vessels using logistic regression

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Table 3: Association of peripheral arterial disease with gender in type 2 diabetes mellitus

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The association of lower-extremity arterial diseases with the age of patients was summarized in [Table 4]. Atherosclerosis and plaques were significantly higher in the age group of 61–70 years and 71–80 years than the other groups; P = 0.004 and 0.019, respectively. Stenosis was found to be higher in the same group than the other groups. Thrombosis was also found higher in the age group of 61–70 and 71–80 years than the others without a significant difference; P = 0.501 and 0.377, respectively. [Figure 1] and [Figure 2] were MDCT images demonstrating the location of atherosclerosis in the arteries of the lower limbs.
Table 4: Distribution of peripheral arterial disease in relation to age of patients

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We performed a logistic regression test to determine the association of PAD with their incidence in the blood vessels using the statistical values of OR, as summarized in [Table 1]. The table contains different values of OR. It was found that atherosclerosis and plaques have higher ORs than the other findings, as shown in [Table 1]. Following the OR values, the FA is more likely to get atherosclerosis by two times, popliteal artery by three times, and posterior tibial artery by 2.7 times. FA is more likely to get plaques by ten times (OR = 10) than the other arteries of the lower limb. Furthermore, the FA artery is more likely to show thrombosis by two times than the other blood vessels of the lower limb, which showed lower ORs. FA, popliteal artery, and anterior tibial artery were more likely to be affected with stenosis than posterior tibial artery and peroneal artery; ORs = 5, 4, and 2 vs. 0.86 and 0.82 respectively.


  Discussion Top


PAD is considered a common vascular complication in T2DM patients, which may contribute to the initiation of diabetic foot ulcers and is an efficient predictor of cardiovascular mortality and morbidity.[10],[11] The study presented the findings of the PAD, which associated with Type 2 DM. Making the diagnosis of PAD is essential to determine the proper treatment. Additionally, determination of the location stenotic segments and the occlusion severity in the lower-extremity arteries is essential for diagnosis and management.

The MDCT findings in this study revealed that atherosclerosis and plaques were the most common findings in the lower-extremity arteries. They were more prevalent in males than females (male: female ratio was 1:0.6). Several studies found that atherosclerosis was the most common vascular abnormality associated with T2DM and cardiovascular diseases.[12],[13] Similarly, our findings agreed with several studies that reported that Type 2 DM is a common risk factor for PAD.[14],[15],[16] Our findings revealed that PAD involves plaques and atherosclerotic disease in the FA, posterior tibial artery, anterior tibial artery, and peroneal artery.

Regarding the plaques, He et al. reported a higher incidence of mixed plaques in DM than non DM.[17] These plaques were detected in the distal lower leg segments. Therefore, T2DM is the most influential risk factor for atherosclerosis.

The present study revealed that stenosis was more likely to affect the FA (OR = 4.8), popliteal artery (OR = 5.6), and anterior tibial artery (OR = 2.6), while posterior tibial artery and peroneal artery were less frequently affected with stenosis. Stenosis is the direct effect of atherosclerosis and plaques in Type 2DM. Zemaitis et al. reported an increased rate of stenosis in DM compared to non DM.[18] In PAD, atherosclerotic plaques narrow the peripheral arterial lumen, which reduces blood flow to the distal extremity. Decreased blood flow leads to generalized pain at the distal part of the lower limb and claudication.[19]

In this study, it was found that thrombosis is less frequent than atherosclerosis and stenosis. It is commonly prevalent in the age of over 60 years. It is found that thrombosis is more likely to increase by 2-fold in the FA than in other distal arteries. Atherosclerosis and plaques were a significant risk factor for FA thrombosis.[20],[21] MDCT angiography allows precise assessment of the thrombosis. It capable of depicting the courses of blood vessels, specifically the completely occluded small segments. Such depictions are useful for planning interventional revascularization procedures.

It was found that atherosclerosis was significantly associated with age in patients with Type 2 DM, exceptionally high in the age groups of 61–70 and 71–80 years with a mean duration of 29 years. It was observed that the incidence increased in patients over 50 years. This finding is consistent with previous studies, which reported that the prevalence of atherosclerosis increased to 29% in patients with Type 2 DM over 50 years of age.[22],[23] Age and duration of diabetes were associated with an increased risk of PAD in patients with DM.[23],[24] Therefore, increasing age will increase the likelihood of developing lower-limb arterial diseases.

In this study, thrombosis was found higher in the age group of 55–76 years than others (14.3%) without significant difference (P = 0.634). MDCT is capable of accurately assessing short-segmental stenosis, which is beneficial for preoperative information such as determining the anastomotic sites for bypass grafting.

PAD's diagnosis still has a significant clinical impact since PAD is considered a marker for systemic atherosclerosis. MDCT provides an accurate diagnosis for evaluating PAD to avoid limb-amputation threatening compromise of blood perfusion (off).

Limitation of the study

The study faced some problems as it was a single-center study. The sample size was not large enough since the cases were taken in a period of 1 year. We recommend further multi-center studies with a large sample size to confirm the initial results of this study.


  Conclusion Top


Atherosclerosis, plaques, stenosis, and thrombosis were the most common abnormalities of PAD in Type 2 DM. They were most prevalent in patients above 60-years-old. PAD was higher in males than in females. MDCT is a useful imaging modality for evaluating PAD since it fast and has high spatial, contrast, and temporal resolution.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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